I am so honored to be able to support you as your doula! Before we meet for our first prenatal, please complete this intake form to help be get a better sense of the kind of birth experience you want and how I can best support you as your doula. We will then go over your responses together.

Pregnant Person Full Name *

Pregnant Person Full Name

First Name

Last Name

Pregnant Person Date of Birth *

Pregnant Person Date of Birth

MM

DD

YYYY

Partner/Support Person Full Name (if applicable)

Other Support Person

Birth Information

Estimated Due Date *

Care Provider *

Birthing Location *

I.e. Home, Hospital, Birthing Center

Have you toured the birthing location?

Yes

Not Yet

It's at home

Have you taken a prenatal class?

Yes

No, but plan to.

No, and don't plan to.

Contact Information

Your home address.

Address *

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone #1 *

Phone #1

(###)

###

####

Partner/Support Person Phone

Partner/Support Person Phone

(###)

###

####

Email Address *

Partner/Support Person Email

Medical History

How much do you usually sleep at night? Do you have an opportunity to rest or nap each day?

What has your prenatal experience been? Emotionally? Physically?

Do you have any allergies (Food, medication, etc) or food preferences?

Medical conditions pertinent to labor and childbirth

None

Gestational Diabetes

Group B Strep

Herpes

Back pain/Injury

Other

Have you ever had any procedures done that might affect your birth experience?

What number pregnancy is this for you?

Childbirth Education

Are you taking childbirth education? If so, please share the date and location.

What would you like to learn in a childbirth class or from our sessions?

Are you and/or your partner/support person reading any books about labor, postpartum time or breastfeeding?

If you’ve already taken a childbirth ed class, please note any topics you want to discuss further:

Ways your labor might begin

Stages of labor

Timing contractions

Natural comfort strategies

Breathing methods

Positions for labor

Unmedicated and Medicated induction

General triage procedures

Common medical procedures used in labor

Pain medications used in labor

Positions for pushing

Episiotomy

Assisted vaginal delivery

Cesarean delivery

Post birth procedures for birth parent

Newborn procedures

Postpartum healing

Feeding & Breastfeeding

Newborn care

Do you plan to take any other classes to prepare (ie. breastfeeding, newborn care, infant CPR, etc.)?

Labor and Birth Preferences

What is your birth vision? If things go perfectly, what does that look like for you?

Have you shared your birth preferences with your care provider?

When does your care provider want you to call them/arrive at the birthing location (in case of a home birth, when does midwife want to join you)?

Have you discussed protocols if you go past your due date?

In what ways are you preparing for this labor and birth?

What do you anticipate will be your greatest challenge while in labor?

What do you anticipate will be your greatest source of strength while in labor?

In previous painful situations (i.e. sickness, headache), what methods have you used to comfort yourself?

In what ways do you hope a doula's support will be helpful to you? What types of assistance do you imagine will be most useful for you?

How does your partner/support person want to be involved in your birth? I.e. Hands on, share support with doula, or let the doula take the lead.

Who would you like to be present during your labor?

Partner

Children

Other family members

Doula

Friends

Other

Do you want any of the following non-medical choices during labor?

Labor at home

Labor in hospital

Wear own gown

Fluids

Ice/Popsicles

Food

Aromatherapy

Music

Walking

Shower/Jacuzzi

Rocking Chair

Do you want any of the following medical choices for Early Labor?

Continuous Fetal Monitoring

Intermittent Fetal Monitoring

No IV or Heparin Lock

IV

Vaginal checks limited to as few as possible

Vaginal checks done per HCP/Staff Protocol

Spontaneous rupture of membrane

Medications offered (i.e. epidural)

Medications not offered

Epidural/narcotics

Do you want any of the following to occur for the birth?

Mom chooses birth positions

HCP chooses birth positions

Pictures

Video

Perineal Massage

Episiotomy

Prefer to tear over episiotomy

Cord cut by Partner

Cord cut by Care Provider

Delay cord cutting

Baby caught by partner with HCP help

Announce the sex of baby

Baby place on mom’s chest immediately

Baby cleaned before given to mom

Delay newborn procedures for one hour

Placenta delivered without Pitocin

If your HCP suggest that you have an induction/Augmentation, do you want any of the follow?

If you have a scheduled Cesarean Section or your HCP states that you need one, do you want?

Epidural

Spinal

Partner present

Doula present

Partner to cut cord if possible

Doula with mom for repair

Pictures/Video

Drape dropped for birth

One arm free to touch baby

Breastfeeding in recovery room

Do you have any special choices?

Save Placenta

Cord Blood

Lactation consultant in-hospital visit.

Do you have any spiritual or religious practices that you would like to incorporate into the birth process or directly after the birth? If so, do you need my assistance with any of this?

Newborn Care & Feeding

What method of feeding your baby are you planning to use?

Do you have any experience with breast/chest feeding? Tell me about it.

Do you have any concerns about your ability to feed your baby?

Do you have any issues/fears/concerns about newborn care?

Postpartum Period

If a hospital birth, do you want to room in with your baby or do you want the baby to go to the nursery with partner/family?

Do you want the HCP/staff to:

Bottle feed

Give Pacifier

Waive eye ointment

Waive Vitamin K shot

Waive PKU test

Waive Glucose test

Waive Hepatitis B vaccine

Circumcision (with anesthesia)

Do you want?

Discharge the same day (if hospital allows)

Lactation consultant

Postpartum doula

Postnatal education class

La Leche League contact

New mother support group

Postpartum depression screening

Do you have any fears or concerns about the postpartum time?

What kind of support will you have? Food/errands/household?

Do you have a pediatrician? If so, who?

Baby's Sex

Male

Female

Other

Unknown

Baby's Name (if you want to share)

Additional Resources

Do you want any additional information on the following:

Care of perineum

Postnatal expectations

C-Section recovery

VBAC-Specific Information

Breastfeeding

Breast pumps

Postpartum Depression

Infant Massage

Diet

Circumcision vs. Intact

Car seat installation and us

Baby wearing

Any additional concerns or information needed or want to share?

Photographic Release *

Ever so often I like to update my website and other printed materials. If you would be willing to allow me to use your photographs, with your name (if desired) taken of your birth (non-explicit photos only), please let me know.